Review: Somatic Awareness and Body Distress Symptoms
The paper reviewed here is ‘Somatic Awareness in the Clinical Care of Patients with Body Distress Symptoms’ by Bakal and colleagues and freely available here. The authors describe Body Distress Symptoms thus
‘Symptoms of somatic or body distress (BD), more widely known as medically unexplained symptoms (MUS) or functional somatic syndromes, are characteri(s)ed by patterns of persistent physical complaints for which adequate examination does not reveal specific pathology’
Thus the authors equate Medically Unexplained Symptoms, functional somatic syndromes and symptoms of body distress in their definition. The authors go on to justify their favouring of the term BD and cite evidence suggesting that reattribution therapy which attempts to move the explanation for functional bodily symptoms to a psychological cause does not lead to an improvement in outcome measures. However the article is concerned with BD rather than RT meaning that the efficacy of RT would be explored in more detail in a systematic review which may result in more complex conclusions. The authors then go on to discuss the origins of Bodily Distress Disorder (BDD), discussing the three factor model and then focusing on how core symptoms might relate to the regulation of breathing.
I disagreed with the section on ‘depression and sadness in context’. While it is important to distinguish between ‘normal’ sadness and depression (for which there are many diagnostic criteria) the authors also make some suggestions about prolonged antidepressant use and then finish the section by stating that they do not think that antidepressant treatment is the answer. I would argue on the other hand that appropriate treatments are made only after a carefully considered assessment and that recommendations regarding the optimal treatment strategies should be guided by this individual assessment, the evidence base and the local treatment protocols.
The authors answer some of these points in their section on tacit knowing and somatic awareness. Even here I would argue that they are discussing an area which includes the clinician’s intuition and that where this is carefully honed it should be consistent with related areas such as the clinical evidence base. I would argue that the clinical evidence base is not an area distinct from clinical accumen but is an investigation of clinical data and an attempt to draw meaningful knowledge from this area. The definition of ‘tacit knowledge’ adds an air of mystery by referring to knowledge at the periphery of attention. Within this section, the authors refer to non-verbal material which the physician may use during the clinical process. Such ‘tacit knowledge’ can be systematically converted into explicit knowledge by a close study of such phenomenon and indeed various methods for measuring such factors have long since been developed and employed both in clinical practice and research.
I found the discussion of somatic awareness to be a more interesting contribution if we consider the mind to be both a function of brain as well as being better described by a symbolic system that differs from that used in discussion of the ‘brain paradigm’ (e.g. see here). I was interested however to find out a little more about how the authors intended to align ‘neurobiology’ and ‘consciousness’ as according to the paradigm discussed in the previous sentence this might not be a suitable starting or indeed end point. The authors invoke some of Damasio’s thoughts on the mind-body relationship. My interpretation of what the authors were trying to say was that there is mind-brain-body relationship and that as the body is involved in this relationship it can serve as the focal point for discussions and that this is just as valid as making the mind or the brain the focal points. The justification for this would be that any ‘focal’ point is in itself a simplification of the more complex relationship that occurs between the three and so it doesn’t matter which of the triad serves as this focal point it will still be a simplification and explanations will always return to the complex interactions between mind, body and brain. However by using the body as a focal point for this discussion, the model is apparently made more accessible.
In the final section the authors consider how ’somatic awareness’ might be incorporated into medical practice. Again I disagreed with many of the points in this section. For instance, the withdrawal of medication was difficult to justify as patients may be on a number of medications for different conditions. Although some may not be prescribed as psychotropics they may in some cases have such side-effects and it would be useful to see the management suggestions in such cases where withdrawal is not possible. As above, a blanket statement about medications does not address the complexities of individual needs and even on a theoretical basis there are many counters to this suggestion. Encouraging a focus on introspection and monitoring both symptoms and bodily sensations seems to be a useful approach that could be developed further in a subsequent article again with reference to the evidence base.
In summary, the authors broach psychosomatic issues by consideration of ‘body distress’ although I found a few statements that seemed axiomatic and could be argued to be too simple to address the complexities of individual needs without careful consideration of process, the evidence base and consequences. It is useful however to have discussions in this area.
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Review: A Meta-Analysis of Psychotherapy in Cluster C Personality Disorders
The paper reviewed here is ‘Follow-up psychotherapy outcome of patients with dependent, avoidant and obsessive-compulsive personality disorders: A meta-analytic review’ by Witold Simon. The title summarises the broad aim of the study and in the abstract, the authors conclude that
‘The study indicates that therapy gains are usually maintained at follow-up for Cluster C clients treated with cognitive-behavio(u)ral and psychodynamic approaches as well as social skills training‘
Just to recap, the DSM-IV cluster C personalities refer to the anxious avoidant personality disorder (AVPD), the dependent personality disorder (DPD) and the Obsessive-Compulsive Personality Disorder (OCPD). In the objectives section, the authors clearly outline the questions they aim to answer including the efficacy of therapy on specific and general outcome measures, efficacy of follow-up, relative therapy responsiveness of individual personality disorder subtypes and relative efficacy of therapy types. The methodology is clearly outlined incuding databases used, search terms within the databases and inclusion criteria for papers. The researchers have used detailed criteria for describing the papers and students were trained to use these criteria with the papers. The criteria scored highly on inter-rater reliability. The authors identified 15 studies between 1982 and 2006. The authors commented on the heterogeneity of treatment approaches as well as in a number of other variables. For each of the four questions they posed, the authors described the number of randomised controlled trials and non-randomised studies. In the results section they state that all of the treatments except brief dynamic therapy were effective in showing ‘improvements’ by the end of therapy compared to controls and referred to Table IV. However on inspection of Table IV, I noted that effect sizes were given but I wasn’t clear about which outcome measures the effect sizes related to. In the section on follow-up therapy the results are discussed for 3 and 6-month follow-ups and given the range of therapies examined the significant findings cover many therapies in individual trials. I couldn’t identify a statistical pooling of study results in the table or the section on follow-up studies. Indeed on closer examination, I could find no reference to effect sizes in the tables or to outcome measures nor any other indication of the effects of treatment. In the text, again I could find no reference to these measures and instead there are general remarks about individual studies or small groups of studies. In the section on differential effects according to diagnosis, the authors report that these results are ‘inconsistent’ and describe these qualitatively without any obvious reference to a pooled-analysis which might at least offer a statistical answer. A little later in the conclusions, the authors refer again to the effect sizes and here they pool the data for effect sizes using Cohen’s Classification. The effect size they explain refers to the percentage of people getting better with therapy. However it is not clear what ‘getting better’ means as improvement might be considered differently in each study and would make comparisons difficult. I didn’t see any other quantitative results given in the discussion.
In summary, perhaps the most convincing evidence was provided for the follow-up data, and here the authors have included the pooled effect sizes although there still remains the question of what exactly is meant here by ‘an improvement’. There is also the question of how diagnoses have been established in each study. For instance there has been a suggestion that anxious avoidant personality disorder has an overlap with social phobia e.g. (Tillfors and Ekselius, 2009). If this is the case it would be interesting to see how social phobia has been excluded in these studies although the authors have referred to the heterogeneity of methodologies in the studies. The lacks of explicitly stated pooled effect-sizes in other sections of the paper make this difficult to interpret and one obvious comment is that a meta-analysis should be repeated as more study results become available although this can be said for all meta-analyses.
References
Tillfors M and Ekselius L. Social phobia and avoidant personality disorder: are they separate diagnostic entities or do they reflect a spectrum of social anxiety? Isr J Psychiatry Related Sci. 46(1). 25-33.
Witold Simon. Follow-up psychotherapy outcome of patients with dependent, avoidant and obsessive-compulsive personality disorders: A meta-analytic review. International Journal of Psychiatry in Clinical Practice. 2009. 13(2). 153-165.
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